Chapter 5: The future relationship and reciprocal healthcare

54.The Joint Report goes a long way towards securing reciprocal healthcare arrangements for those UK and EU citizens who by the time of Brexit have exercised free movement rights and are residing in another EU country. But many other issues are not covered in the Joint Report, and can only be addressed by means of a separate agreement on future relations. Those negotiations have, at the time of writing, yet to start.

55.This chapter therefore outlines the issues that we believe future discussions on reciprocal healthcare will need to consider.

Affected groups

Short-term visitors

56.Short-term visitors usually access health services through the EHIC system. The Joint Report covers only those persons who are travelling at the point of Brexit: in other words, a UK citizen on holiday in the EU on 29 March 2019 (if that is Exit Day) would retain the right to access healthcare by means of the EHIC until his or her return to the UK. But it offers no protection to UK citizens travelling to the EU after 29 March 2019. Nor does it offer protection to EU citizens travelling to the UK after that date.

57.If the EHIC is not maintained in its current form, short-term visitors might instead, as the BMA told us, need to purchase individual travel insurance.82 This could in turn have implications for the price of travel insurance. Hugh Savill of the ABI said that the loss of the EHIC would require policies to “absorb the medical costs currently covered” by the card; indeed, “the highest cost of travel insurance is medical costs”.83 Mark Dayan told us that without the EHIC the liability of travel insurance companies in the UK would increase, and “their prices to consumers would increase” in tandem.84 Hugh Savill gave a “finger in the air” guess that there could be a hike of between 10% and 20% in the price of insurance premiums.85 He felt that although the loss of the EHIC would affect everybody, certain groups—such as elderly travellers—were “likely to bear a higher proportion” of increases in costs, on the basis that they were more likely to claim.86

Box 7: Features of the travel insurance market

There are two types of travel insurance:

single-trip; and

multi-trip. Multi-trip policy (covers the traveller for a particular year).

In 2016:

13.2 million travel policies sold—2.7 million were single-trip polices; 10.4 million multi-trip policies.

£369 million—total claims made; of which £199 million were for medical expenses.

£156 million—estimated medical costs associated with the treatment of British citizens under the EHIC.

Source: Written evidence from the Association of British Insurers (BRH0024)

58.The many people with long-term conditions, including kidney patients, and people with disabilities, will be particularly affected, given the prohibitive costs of travel insurance that they face.87

Patients with long-term conditions

59.Treatment that might be necessary for patients suffering from long-term conditions while on a short visit to another Member State is reimbursed by the patient’s sponsoring state under the EHIC scheme. For the Academy of Medical Royal Colleges, this meant that patients with such conditions could travel across UK and EU borders “without the need for expensive travel and health insurance”.88

60.29,000 people in the UK currently receive kidney dialysis, typically three days a week. If the frequency of dialysis is reduced, even for a short period, the health of the patient deteriorates rapidly, in most cases requiring intensive and expensive specialist treatment.89 The EHIC enables UK kidney patients to get the treatment that they need while travelling in the EU or EEA. According to Kidney Care UK, the “fundamental issue with dialysis is … ease of access and we presently have a simple system to access care in other parts of Europe.”90

61.Kidney Care UK stressed the importance of travel for the wellbeing of kidney patients and their families. They gave the example of one dialysis patient, Amanda, for whom the ability to take holidays “gives her the sense of freedom she so often feels is lost to her”.91

62.The organisation argued that people who needed dialysis would therefore be among those “most seriously affected” by any loss of reciprocal healthcare rights. Patients were anxious that their freedom to travel could be curtailed, because without access to treatment, travelling or working in the EU for longer periods of time would be “prohibitively expensive”. This was largely because existing travel insurance policies did not provide cover for such care.92

Box 8: Arranging dialysis abroad

Before they travel, people who use dialysis currently need to make arrangements with a clinic in the area that they are travelling to, in order to secure dialysis sessions. Such sessions are known as ‘Dialysis Away From Base’ (DAFB), and are funded through the UK’s reciprocal healthcare arrangements. EU dialysis units charge from €250 to €450 per session, with most costing towards the lower end of that range. Since dialysis is required three times per week, this gives weekly costs of between €750 and €1,350 that patients would need to fund themselves if no reciprocal healthcare arrangements were in place.

It is difficult to obtain data on how many EU/EEA citizens access dialysis treatment in the UK. This is because there are few opportunities for EU/EEA patients to obtain spaces for dialysis at UK NHS units.

Patients with rare diseases

63.Rare diseases are those that affect no more than five in 10,000 people. Taken together, between 6,000 and 8,000 rare diseases affect the daily lives of around 30 million people in the EU, many of them children. According to the UK Coordinators of European Reference Networks, such diseases can cause chronic health problems, many of them life-threatening.93

64.When patients are referred by a doctor in their country of residence to a specialised provider in another EU Member State, the mechanism used is the S2 system. Alternatively, patients can use the route offered by the EU Directive on Patients’ Rights in Cross-border Healthcare.94 For the UK Coordinators of European Reference Networks, stopping these reciprocal healthcare mechanisms would mean that UK patients would no longer be able to access elective care in the EU, unless they covered the cost themselves.95

People with disabilities

65.The BMA told us that people with disabilities would potentially be among the most affected by any loss of reciprocal healthcare rights. Without the EHIC, for example, individuals with a disability might find that purchasing travel or health insurance could be “especially expensive and potentially difficult to arrange”. This could either reduce their ability to travel, or significantly increase the risk of their travelling without insurance.96 Unlike the EHIC, which is available to all free of charge, we were told by the Law Society of Scotland that some 26% of disabled adults already felt that they were charged more for travel insurance, or simply denied it, because of their conditions.97

66.For these reasons, the BMA suggested that the Government should make a full assessment of the potential impact of the loss of reciprocal healthcare arrangements on affected groups, including individuals with disabilities.98

67.Lord O’Shaughnessy provided us with the table below. The table summarises how the Joint Report covers the rights to reciprocal healthcare of certain groups of people, whereas other groups’ entitlements will be discussed as part of the negotiations on the future relationship.

Cohort (and examples)

Agreed in principle rights

People resident in another EU Member State on the specified date [29 March 2019].

UK state pensioner aged 70 living in Spain and already covered for reciprocal healthcare.

UK Early retiree aged 50 living in Spain and expecting to obtain reciprocal healthcare once they start drawing their state pension.

Ongoing right to reciprocal healthcare (once they reach state pension age).

The right endures for as long as they remain permanently resident in the EU.

Those who are UK state pensioners on the specified date can use a UK EHIC if they require needs-arising healthcare while on a temporary stay in another Member State (e.g. a resident of Spain on holiday in France with a UK EHIC).

People who have paid contributions in another Member State before the specified date.

UK national (of any age) who has at some point in the past worked in France and paid into their system.

Ongoing right to reciprocal healthcare, if they move to the EU, and once they reach state pension age.

UK citizens resident in the UK on the specified date who do not have a history of working in the EU.

UK state pensioner age 70 living in Liverpool (and has not worked in EU).

Working-age UK citizen living in Liverpool (who has not worked in EU).

None—the Commission sees this as for the future relationship.

Anyone receiving relevant Department of Work and Pension (DWP) benefits and resident in the EU on the specified date.

Ongoing right to reciprocal healthcare, for as long as they draw the DWP benefit and remain resident in the EU.

Frontier workers

Someone living in one Member State but working in another.

Agreement in principle that people who have begun frontier work before the specified date can receive reciprocal healthcare for the duration.

Posted workers

Someone living full-time in another Member State because their employer in their home country has posted them there.

No agreement in principle—the Commission sees posted work as a matter for future talks.

Dependents

Dependents of the groups above (who are in receipt of a state pension, DWP benefit, or who are a frontier or posted worker).

Agreement in principle that dependents can continue to receive healthcare.

European Health Insurance Card

UK temporary visitors to the EU currently can use an EHIC to access needs-arising care. This includes tourists and students.

‘Pragmatic’ agreement in principle will ensure EHIC remains valid for the duration of any stay that crosses over specified date, e.g.

A holiday that started before the specified date; or

A course of study begun before the specified date.

Planned treatment (S2 route)

UK residents who can currently travel to the EU to receive NHS authorised medical care, or to give birth in a home country.

‘Pragmatic’ agreement will allow people to finish courses of treatment/maternity care that began before the specified date.

There is no broader agreement with the Commission about ongoing S2 rights.

Source: Supplementary written evidence from the Department of Health and Social Care (BRH0028)

The effects of loss of reciprocal healthcare arrangements

68.Many witnesses argued that changes to healthcare provision would discourage further migration to the UK by EU or EEA citizens. For some this may be a desirable outcome, and the Government itself has set an objective of reducing long-term net immigration. But the Academy of Royal Medical Colleges noted that such a reduction would have a particular impact on the health and social care workforce.99 The Academy also believed that high insurance costs would be a disincentive to EU citizens, including tourists, considering short-term travel to the UK post-Brexit.100

69.The Academy of Medical Royal Colleges were therefore clear that “the same rights should be extended to all citizens who move across the UK and EU borders in the future”101. And the BHA supported the idea of ensuring that, post-Brexit, rights of access to reciprocal healthcare should encompass future flows across borders, replicating current rights to healthcare provided by EU freedom of movement provisions.102

70.Kidney Care UK also urged that the right of UK citizens to hold an EHIC be retained,103 while the Royal College of Physicians of Edinburgh hoped that “in any negotiations or legislation regarding future reciprocal health arrangements with the remaining 27 EU countries … affected groups will have the same rights and entitlements as everyone else.”104 This would include the rights of people with rare diseases to continue accessing healthcare using the S2 or Patients’ Rights Directive.

71.There is some indication that the Government agrees with these ambitions. Paul Macnaught of the Department of Health and Social Caresaid that the Government was “seeking to clarify the position on EHIC … to provide as much certainty to people ahead of exit day” as possible.105 His Department wrote that it was “optimistic” that talks on a future relationship with the EU would secure the continuation of reciprocal healthcare rights.106 Lord O’Shaughnessy told us that the while the Joint Report represented a “good outcome”, the Government had always wished to “go further” and “replicate” existing arrangements in order to “effectively maintain the system we have now”.107 But because the EU’s negotiating mandate did not cover future relationship issues, they were unable to discuss these aims in phase 1.108

72.On the other hand, Mark Dayan had already suggested to us that the Government’s ambition to maintain current arrangements might meet resistance from the EU negotiators:

“There are more general issues. Something that unfortunately is the case for reciprocal healthcare … is that the issues will be settled in part not in their own right but by wider principles in the negotiations. A significant one for reciprocal healthcare, on which the EU27 so far seem fairly united, is a degree of resistance to the idea of the UK cherry-picking certain programmes to remain a part of while leaving the single market and no longer having free movement of people.”109

Conclusions

73.The Joint Report covers only the free movement healthcare rights of UK and EU citizens who are resident in another Member State before Brexit. It says nothing of whether and how the reciprocal healthcare entitlements of other UK and EU citizens will be protected post-Brexit. In the absence of an agreement on future relations that covers this topic, the rights currently enjoyed by 27 million UK citizens, thanks to the EHIC, will cease after Brexit. Other rights, provided for by the S2 scheme and Patients’ Rights Directive, will likewise come to an end.

74.Our evidence suggests that it is not in the UK’s interest for reciprocal healthcare arrangements to cease. Because of higher insurance costs—and in the case of dialysis patients, people living with rare diseases, and disabled people, the difficulty of obtaining travel insurance at all—without EHIC or an equivalent arrangement it will become much more expensive for UK citizens with chronic conditions to travel to the EU post-Brexit, for holidays, recuperation or treatment.

75.The Department of Health and Social Care wishes to continue to maintain reciprocal healthcare arrangements, including the EHIC, post-Brexit. We applaud the spirit underlying this ambition, but it is difficult to square it with the Government’s stated aim of ending freedom of movement of people from the EU.

76.More generally, reciprocal healthcare arrangements will only be achieved by agreement between the UK and the EU. The Government has not yet set out its objectives for the future UK-EU relationship. We therefore urge the Government to confirm how it will seek to protect reciprocal rights to healthcare of all UK and EU citizens post-Brexit, as part of any agreement on future relations.